title: Heparin and protamine titration do not improve haemostasis in cardiac surgical patients.
abstract: OBJECTIVE
  Weight-based heparin and protamine dosing strategies for cardiopulmonary bypass (CPB) do not take into account interpatient variability in drug sensitivity and may result in bleeding complications. We compared the Hemochron RxDx heparin and protamine titration system with standard weight based management with regard to heparin dose, protamine dose, and perioperative bleeding.
  
  
  METHODS
  One hundred and thirty-five cardiac surgical patients were randomised into four groups. Group 1 received standard heparin and protamine management: Group 2 received heparin and protamine by in vitro titration. Group 3 had the heparin dose titrated, and group 4 had the protamine dose titrated. Coagulation tests, bleeding, and transfusion requirements were measured.
  
  
  RESULTS
  The initial heparin bolus predicted by the titration was < 300 U.kg-1 in all patients. Group 2 received a lower heparin bolus for the initiation of bypass but total heparin doses were not different among groups (group 1 = 365 +/- 43, group 2 = 348 +/- 73 U.kg-1, group 3 = 394 +/- 86 U.kg-1, group 4 = 376 +/- 60; P = 0.06). Groups 2 and 4 received a lower initial and a lower total protamine dose (total dose group 1 = 4.03 +/- 0.65 mg.kg-1, group 2 = 3.56 +/- 1.11 mg.kg-1, group 3 = 4.22 +/- 0.90 mg.kg-1, group 4 = 3.38 +/- 0.98 mg.kg-1, P = 0.001). The incidences of incomplete heparin neutralisation (P = 0.14) and heparin rebound (P = 0.1) were not different among groups. Postoperative bleeding and transfusion requirements did not differ.
  
  
  CONCLUSIONS
  In cardiac surgical patients, heparin and protamine titration did predict a lower protamine dose but did not result in a measurable improvement in haemostasis during the perioperative period.
authors.affiliation: Department of Anesthesiology, Mount Sinai Medical Center, New York, NY 10029, USA. linda_shore@SMTPLINK.MSSM.EDU
authors.forename: L
authors.initials: L
authors.lastname: Shore-Lesserson
authors.forename: D L
authors.initials: DL
authors.lastname: Reich
authors.forename: M
authors.initials: M
authors.lastname: DePerio
mesh_terms: D000704:Analysis of Variance; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D001780:Blood Coagulation Tests; D016063:Blood Loss, Surgical; D001803:Blood Transfusion; D001835:Body Weight; D006348:Cardiac Surgical Procedures; D002315:Cardiopulmonary Bypass; D016009:Chi-Square Distribution; D004305:Dose-Response Relationship, Drug; D004322:Drainage; D016903:Drug Monitoring; D005260:Female; D005544:Forecasting; D006488:Hemostasis, Surgical; D006493:Heparin / Q000008:administration & dosage* / Q000009:adverse effects; D006494:Heparin Antagonists / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D015994:Incidence; D007430:Intraoperative Care; D008297:Male; D019106:Postoperative Hemorrhage / Q000209:etiology; D011446:Prospective Studies; D011479:Protamines / Q000008:administration & dosage* / Q000009:adverse effects; D017186:Titrimetry
chemical_list: D000925:Anticoagulants; D006494:Heparin Antagonists; D011479:Protamines; D006493:Heparin